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*&ii 4 





VADM Wiilard F. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM H.A. Sparks, MC, USN 
Deputy Surgeon General 



Director of Public Affairs 

LTJG Richard A. Schmidt, USNR 

Editor 

Jan Kenneth Herman 

Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 

Nancy R. Keesee 



U. S. NAVY 
MEDICINE 



Vol. 70, No. 6 
June 1979 



1 From the Surgeon General 

2 Department Rounds 

"Whirlwind Special" Nets Navy Nurses . . . San Diego Dental Officers 
CPR Certified 



Contributing Editors 

Contributing Editor-in-Chief : CDR E,L. Tay- 
lor (MC); Dental Corps: CAPT R.W. Koch 
(DC); Education: LT R.E. Bubb (MSC); Oc- 
cupational Medicine: CDR J.J. Bellanca 
(MC); Preventive Medicine: CAPT D.F. 
Hoeffler (MC) 



5 BUMED SITREP 

6 Scholar's Scuttlebutt 

Information Assistance for the Armed Forces Health Professions Schol- 
arship Program 

8 Notes and Announcements 



POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed ate those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the- Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the ciled reference. 

DISTRIBUTION: U.S. Nary Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Navy Medicine, Department of 
the Navy. Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372. Telephone: {Area Code 202) 254- 
4253. 254-4316. 254-4214; Autovon 294-4253. 294-4316, 294- 
4214. Contributions from the field are welcome and wilt be 
published as space permits, subject lo editing and possible 
abridgment. 

The issuance of this publication is approved in accordance 
with Department of the Navy Publications and Printing 
Kegulations (NAVEXOS P-35). 



10 Independent Duty — Update 

Gaining Patient Compliance 
CDR J.J. Bellanca, MC, USN 

11 Features 

SPRINT: A Psychiatric Contingency Response Team in Action 
CDR T.G. Carlton, MC, USN 

12 Navy Energy Conservation: Status Report 

22 Professional 

Pulmonary Function Testing in the Navy Asbestos Medical Monitoring 

Program 

LCDR S.K. Cowles, MC, USN 

26 Screening of Alcoholism 

LT R.N. Sampson, MSC, USN 



COVER: The new wing at the National Naval Medical Center, Bethesda, 
Md., is a showplace of energy efficient design and has the latest in energy 
monitoring and control equipment. 



NAt M£H i>.J0SH 



Perspective Commanding Officers 



On 21 May 1979, VADM Arent- 
zen addressed a group of perspec- 
tive commanding officers at the 
Naval School of Health Sciences. 
Although his remarks were directed 
to this group, many individuals felt 
that the Surgeon General's thoughts 
should be shared with other mem- 
bers of the Naval Medical Depart- 
ment. 

U.S. Navy Medicine here reprints 
the speech in its entirety. 



You are about to commence a 
short course of study designed spe- 
cifically to help prepare you for the 
major task you will soon undertake. 
This course is designed to equip you 
with some of the necessary tools re- 
quired when you assume command. 
Highly skilled leaders having both 
applied skills and broad perspec- 
tives are required. These next few 
days will not transform you into that 
super being just referred to. Per- 
haps you will never become that 
Figure and most of the experience 
and background has already been 
accomplished by your years and 
growth in the health care field. 
These qualities, already amply 
demonstrated, are why you have 
been chosen to be here in the first 
place. 

The perspective of command is a 
rare privilege and is one which must 
be experienced to be appreciated. It 
can be immensely satisfying as I can 
personally testify. But like most 
things satisfying, it requires the 
exercise of self-disciplined respon- 
sibility. 

Your concerns must go far beyond 
the everyday mechanical manage- 
ment and direction of your respec- 
tive commands. Those concerns 
must be related to where that com- 



mand fits into the greater organiza- 
tion, what the purpose of that 
greater organization is, and where it 
is going. This implies attention to 
people, their needs, and reciprocal- 
ly what the corporate need for 
people may be. 

For some time I have realized that 
the reservoir of operational experi- 
ence among our senior Medical De- 
partment officers — those who are 
prepared to direct, and perhaps to 
command the provision of opera- 
tional support in time of combat or 
war — is diminishing rapidly. Simi- 
larly, we still have too few officers 
who are trained to assume top 
management roles in all our medical 
facilities. In these ever-changing 
and unpredictable times, we must 
be prepared for any contingency, 
and must maintain both the func- 
tional capability, and the leadership 
capability, to do our job. We must 
prepare our potential leaders to 
serve as both health professionals 
and top-level policymakers, ashore 
and afloat. 

However, even with the develop- 
ment of a planned nucleus of 
trained professionals, I am still con- 
cerned for a most important reason 
— a reason that I have stressed 
many times in the past: The key to 
our survival and continued success 
is retention. Without it, our trained 
leaders, our corporate body of 
knowledge, will disappear from the 
active scene. My concern about re- 
tention is not limited to the junior 
officers of the Medical Department, 
and our enlisted personnel. 1 am 
equally concerned, perhaps more 
concerned, about the senior officers 
and senior enlisted people who 
leave active duty with 20 years or 
more service. We must retain not 
only our followers but our leaders. 



They are our corporate body of 
knowledge and experience for the 
future. We must not only train our 
leaders, but use them to the fullest 
extent of their capabilities. We 
must continue our efforts to make 
professional growth and develop- 
ment a never-ending and readily 
available option for all those whom 
we count upon for leadership when 
the chips are down. The best way I 
know to prevent professional obso- 
lescence is to avoid it in the first 
place. 

Leaders are inspired by their fol- 
lowers. Those who enjoy success in 
command are ever conscious of the 
forces they employ in achieving 
their success. Their orders and in- 
structions are communicated in a 
fashion that enables all personnel of 
the command to work together in 
the general interests of the team, 
rather than the special interests of 
individuals. The commanding offi- 
cer is, by definition, the only execu- 
tive whose responsibility is the 
whole of the command, rather than 
a segment of it. Yet, ironically, the 
commanding officer cannot fully 
discharge this responsibility with- 
out a great deal of help from many 
people, each of whom should have 
some idea of where they and the 
others are supposed to be going. 
Each person or group of persons 
must be as thoroughly familiar with 
what is expected of others as what is 
expected of them; and they should 
not have to guess what you think of 
the efforts of others, as well as their 
own efforts. The word must be 
passed — in person as often as possi- 
ble — but always passed, horizontal- 
ly, vertically, and deliberately. 

You as commanding officers must 

(Continued on p. 29) 



Volume 70, June 1979 



DEPARTMENT ROUNDS 



"Whirlwind Special" Nets Navy Nurses 



"It's hard to show people an aircraft 
carrier on the Missouri River." This 
is how one Chicago-based recruiter 
described the problem of midwest 
recruiting. In an effort to correct the 
situation, Area Five recently invited 
21 midwest nurses and nursing stu- 
dents to spend four days touring 
Norfolk Naval Base. The tour, aptly 
named the "Whirlwind Special," 
began with a visit to the Portsmouth 
Naval Regional Medical Center, 



where the visitors met with their 
active duty counterparts. 

During the extensive hospital 
tour which followed, they were 
given every opportunity to compare 
notes and talk shop with their sea- 
service counterparts. The results 
were immediate. Said one senior 
nursing student from Milwaukee, 
"I came not really knowing what to 
expect from nurses in the Navy. I 
was surprised and pleased to meet 



so many people who seemed genu- 
inely happy and content with their 
work." Said another, "I was over- 
whelmed by the professionalism 
and pride of everyone we met . . . 
and they were all so friendly, not at 
all rigid and military." 

Not content to show only the 
Navy's medical side, the tour con- 
tinued aboard the aircraft carrier 
USS Nitnitz and the submarine 
tender USS LY Spear. "If all we 




Aboard the Spear, LT Thompson explains the working of the ship's helm. 



U.S. Navy Medicine 



wanted to show them was a hospi- 
tal, we could have taken them to 
Great Lakes," said LT Clark 
Thompson, Medical Recruiter of 
Recruiting District Minneapolis. 
"Norfolk offered a better first expo- 
sure, overall," he added. 

Predictably, the midwesterners, 
many of whom had never even seen 
the ocean before, were awed by the 
immensity of the aircraft carrier and 
the complexity of the tender's many 
repair shops and facilities. 

Aboard the Spear, there was an 
unexpected treat when the tour 
group met some of the First Navy 
women assigned to shipboard duty. 

All were impressed, both with the 
size and complexity of what they 
saw, and with the obvious pride and 
professionalism of the WAVES they 
spoke with. 

In an attempt to present a well- 
rounded view of Navy life, the Area 
Five escorts decided to show their 
charges a little about "pulling 
liberty" as well. With ample off- 
duty time programmed into the 
tour's itinerary, the nurses were 
treated to a night at a local disco, a 
visit to the base exchange, and a 
reception at the Breezy Point Offi- 
cers' Club. For many, the opportu- 
nity to have their pictures taken 
with an admiral at the reception was 
one of the highlights of the trip. 

The trip, according to LT Ander- 
son, was an overwhelming success. 
"Some of these women came here 
with stereotypes and preconceived 
notions about the Navy and Navy 
medicine that we could't budge with 
a crowbar," he said. "The only pic- 
ture they had of the Navy stemmed 
from their fathers' war stories." 
"Their main concern, when we first 
approach them in their junior year 
at school," he went on, "is for their 
careers. They see the Armed Forces 
as second class health care provid- 
ers. The travel sounds enticing to 
them, but they are surrounded by a 
'professional aura' from their first 




The tour group meets one of the first Navy women assigned to shipboard duty, 
HM1 June Stokes (tight), an ex-Army combat medic. 



day in nursing school, and don't 
want to sacrifice that by working for 
something they perceive as second- 
rate." 

One of the methods used to help 
overcome this misconception, is 
selling the continuing education 
programs for Navy nurses. "We 
explain the workings of HSETC 
(Health Sciences Education Train- 
ing Command), and its Navy-funded 
practitionership education pro- 
grams at civilian universities and 
the in-service education for relicen- 
sure at the hospitals, and they begin 
to see us in a different light. " Under 
the auspices of HSETC, a nurse 
who showed interest and aptitude in 
a specific career field, would be sent 
for full or part-time study at a major 
accredited university, while per- 
forming the clinical work at the 
nearest government hospital. "For 
example, we sent the nurse anes- 
thetists to study at Georgetown 



University, while they do their clini- 
cal work at Bethesda," he said. 
Other practitionerships available 
through this program include: pe- 
diatrics, ob/gyn, and family nurse 
practitioner. "Once they see we're 
a professional health-care organiza- 
tion, the only hurdle left to over- 
come is the stereotype about Navy 
life and military service in general 
. . . which is where this trip came 
in." 

According to LT Anderson, most 
of the women who arrived at Norfolk 
with stereotypes and misconcep- 
tions did a complete turnaround in 
their attitudes by trip's end. 

If successful recruiting is meas- 
ured in numbers, the tour was a 
blockbuster. Fifteen of the twenty- 
one nurses have since joined the 
Navy! "One thing's for certain," 
added LT Anderson, "we're defi- 
nitely going to do this again." 

— Story and photos by PH2 W. Breyfogle 



Volume 70, June 1979 



San Diego Dental Officers CFR Certified 



The importance of Basic Cardiac 
Life Support in the management of 
life-threatening emergency situa- 
tions, both in medical and dental 
treatment facilities, and "out on the 
streets," is well known. Because of 
this, a growing number of state 
licensure boards are demanding 
that doctors have valid CPR (Car- 
diopulmonary Resuscitation) cards 
from either the American Heart As- 
sociation (AHA), or the American 
National Red Cross (ARC) when 
applying for licensure or relicen- 
sure. Hospitals are demanding cer- 
tification for every doctor and nurse 
on their staffs. Many experts pre- 
dict that the defensive posture in 
malpractice litigation arising from 
the management of an office emer- 
gency will be severely compromised 
in the future if the doctor involved is 
not certified in CPR. The state of 
California recently enacted legisla- 
tion which indirectly implies that 
rescuers are protected under the 
Good Samaritan "umbrella" only if 
they carry a current AHA or ARC 
card in Basic Cardiac Life Support. 

In 1977, over 640,000 Americans 
died from heart attacks alone, and 
nearly 60% of those died within two 
hours, before even reaching a hos- 
pital! With an increasing geriatric 
population — many of whom are re- 
tired military — there is the potential 
that a large number of medically- 
compromised patients will be seen 
in military dental clinics for routine 
and/or emergency dental treat- 
ment. This then places a burden 
upon Navy dental officers because 
of the risk that a life-threatening 
emergency might occur while these 
patients are under treatment in the 
clinics. 

Recognizing these increased lia- 
bilities and changing legal trends, 




CDR R. Vosskuhler, DC, USN (seated, in background), a certified CPR instructor 
with the American Heart Association, observes his group of dental officers as they 
master the technique of cardiopulmonary resuscitation. 



and realizing the importance of hav- 
ing every dental officer fully trained 
in the management of office emer- 
gencies, RADM William L. Darnell, 
Commanding Officer of the San 
Diego Naval Regional Dental Cen- 
ter, and CAPT Erwin J. Heinkel, 
Jr., Director of Clinical Services for 
the San Diego Naval Regional 
Dental Center, initiated an effort 
which has resulted in the full certifi- 
cation of nearly every officer as- 
signed to the regional center in 
Basic Cardiac Life Support (CPR). 
This is the first time a region- wide 
CPR effort has been sponsored in 
San Diego, and the effort included 
satellite clinics as far away as 
Yuma, Arizona. The San Diego 
County Heart Association whole- 
heartedly supported the concept 
and generously supplied all of the 
logistical support for the courses, 



which resulted in the certification of 
128 Dental Corps officers and three 
Medical Service Corps officers. 

This week-long series of CPR 
classes was coordinated by CDR 
Roger Alexander, an instructor, in- 
structor-trainer, and member of the 
CPR Committee for the San Diego 
County Heart Association (the only 
dentist on that committee). He was 
assisted by CAPT V. Roger Tibbetts 
and LTs Vince Williams and Mark 
Meredith of the San Diego Naval 
Regional Dental Center, CDR 
Robert Vosskuhler of the USS Kitty 
Hawk, and LT Gary Reinhart of the 
San Diego Naval Regional Medical 
Center. All are certified as CPR 
instructors for the San Diego County 
Heart Association. Also included in 
each class was an extra hour and a 
half presentation on the prevention 
and management of dental office 



U.S. Navy Medicine 



emergencies, which was correlated 
with the materia] presented in the 
standard CPR curriculum. Naval 
Regional Dental Center San Diego 
hopes to be able to sponsor similar 
classes in the near future for dental 
technicians, civilian dental assist- 
ants, and hygienists, with particular 
attention given to the training of 
those personnel who stand after- 
hours watches. The training of 
support personnel will result in the 
dental officer-rescuer having an 
extra pair of hands during an emer- 
gency; there have been several 
documented cases where CPR- 
trained auxiliary personnel have 
saved the life of the doctor! 

The classes were enthusiastically 
received by the officers involved 
and many expressed the feeling that 
for the first time they were confi- 
dent of being able to physically and 
mentally cope with a life-threaten- 
ing emergency if such an event oc- 
curred in their offices, homes, or on 
the streets. As mute testimony of 
the course's value, within 10 days 
following the classes, students put 
their newly gained knowledge to 
good use. LT James Anderson 
saved a drowning victim at a Coro- 
nado beach and LT Marshall 
Batchelor was able to provide life 
support to a heart attack victim until 
further help arrived. It is antici- 
pated that these two saved lives are 
only a beginning, and that more 
lives will be saved by Navy dental 
officers in the future. 

It is hoped that this effort will 
spark similar programs in other 
dental regions and insure that each 
and every dental officer and techni- 
cian is fully trained in this most es- 
esntial life-preserving technique. 
Not only will our patients and com- 
munities benefit but our legal 
vulnerability will hopefully be less- 
ened. 



— CDR Roger Alexander. DC, USN, NRDC 
San Diego. Calif. 92136. 



BUMED SITREP 



TUBERCULOSIS CONTROL PROGRAM ANALYSIS COMPLETED 

A preliminary analysis of 1978 data has just been completed. Tuberculin 
reactors reporting to Navy and Marine Corps recruit training centers repre- 
sent approximately 2.5 percent of the population. This continues the trends 
evident in recent years, but is a significant decrease when compared with 
the studies of Comstock and Edwards, who noted approximately 5,6 per- 
cent reactors among incoming recruits in 1969. Tuberculin converters, 
ashore and afloat, averaged approximately 1.7 percent of individuals 
tested. Compliance in tuberculin testing was approximately 82 percent for 
forces afloat (nearly 100 percent for PACFLT vessels), but only 50 percent 
for shore based commands. Navy Medical Department activities were par- 
ticularly poor in their response to periodic tuberculin testing. This lax 
compliance is particularly hazardous since it is generally accepted that 
medical and paramedical personnel are at special risk for exposure to unde- 
tected and uncontrolled cases of pulmonary tuberculosis. There were 95 
active duty personnel admitted for tuberculosis during 1978; of these, 88 
patients had active pulmonary disease. The rates were highest for individ- 
uals of Asian and Malayan ancestry, and lowest for Caucasians. The overall 
incidence for pulmonary tuberculosis among active duty Navy and Marine 
Corps personnel during 1978 was 13.2 per 100,000, as compared with 18.1 
per 100,000 for 1977. Evaluation of data for recent years is continuing. 



Surgeon General Announces New 
Director on 81st Anniversary of 
Hospital Corps 

"June 17th marks the 81st Anniversary of the Hospital Corps. It is a 
time for celebration, reflection, and rededication. I commend all 
members of the Hospital Corps and their families for their dedicated 
efforts and much needed support. 

The history of the Hospital Corps during the past 81 years has been 
a record of outstanding and illustrious service in all parts of the world, 
wherever the Navy and Marine Corps have been in peace and in war. 

As you celebrate this 81st Anniversary, let us not forget that it a 
time honored commemoration of a long and proud heritage of those 
who served before us. It is upon this tradition that the Hospital Corps 
must continue to build for the future. It is incumbent on all of us, 
especially our senior hospital corpsmen, to pass their dedication and 
high standards on to the leaders of tomorrow. In furtherance of this, I 
am very pleased to announce that Master Chief Hospital Corpsman 
Stephen Brown assumes the duties of Director of the Hospital Divi- 
sion on 17 June 1979. 

Thank you for a job well done." 



Volume 70, June 1979 



SCHOLAR'S SCUTTLEBUTT 



Information Assistance for the Armed Forces 
Health Professions Scholarship Program 



If you are a member of the Navy Medical Department, 
or are enrolled in one of its subsidized medical educa- 
tion programs, you may be called upon by medical stu- 
dents to answer a variety of questions concerning 
membership in the Armed Forces Health Professions 
Scholarship Program. The following outline contains 
information on which to base such a response. 

Basic Qualifications 

To qualify for a Navy Health Professions Scholarship, 
students must be formally accepted for the next enter- 
ing class or be currently enrolled in an AMA or AOA 
approved school of medicine or osteopathy in the 
United States or Puerto Rico. Students must he citizens 
of the United States, be of good moral character, and 
meet the physical requirements for a Navy commission. 

Benefits 

Health Professions Scholarships provide: 

• Up to four full years tuition, including all authorized 
fees. 

• Reimbursement for approved books and supplies that 
are required purchases. 

• Full active duty pay and allowance at the Ensign (01) 
pay grade for 45 days each year while performing Ac- 
tive Duty for Training. If academic schedule will not 
permit active duty service away from school, students 
will remain at their school for such an assignment. 

• A monthly stipend of $400 for 10.5 months each year. 

• A commission as Ensign in the United States Naval 
Reserve. 

Benefits begin upon entrance into the program or at 
the beginning of the academic year, whichever is later. 
In the absence of legislative relief, the entire scholar- 
ship benefit package is subject to federal income tax 
(To date, periodic legislative relief has been provided 
since inception of the program). 



45 Days Active Duty for Training 

ACDUTRA can be spent in: 

• School Clerkships (required or elective). 

• Navy Clerkships (clinical or research). 

• Military indoctrination courses. 

• Orientation cruise at sea. 

Service Obligations 

• Scholarship students serve two years on actice duty 
for the first two years of program participation or any 
portion thereof, and six months for each additional six 
months of scholarship support. 

• If this is the first period of active service or partici- 
pants are reentering active service after severing all 
previous connections with any military service, a mini- 
mum three- year active service obligation is incurred. 

Graduate Medical Education 

• All scholarship students are required to apply for in- 
ternships in naval hospitals. Those selected will be 
ordered to active duty and assigned to their training 
hospitals with full active duty pay and allowances. 
Scholarship students not selected for training in a 
Navy facility may request a delay in active service to 
complete their internship in a civilian institution 
without pay from the Navy. Active service may also be 
deferred to permit completion of residency training in 
approved specialties. 

• The time scholarship students spend while in gradu- 
ate medical education programs does not count toward 
their active duty obligation. However, they do not incur 
any additional service obligation while serving as 
interns or residents provided they have at least two 
years of obligation remaining at the end of such train- 
ing. 

• Active Duty Assignments include: 
Submarine Medicine 



6 



U.S. Navy Medicine 



Aerospace Medicine 

Ships 

Regional Medical Centers 

Naval Hospitals 

Dispensaries and Clinics 

Antarctic Research Expedition 

Fleet Marine Force 

Variable Incentive Pay (VIP) 

Under current regulations, volunteer physicians are 
eligible for VIP, Officers who are repaying initial active 
duty obligations or are currently undergoing Graduate 
Medical Education are not eligible for VIP. 

If you talk to students who are interested in applying 
for a medical scholarship in the Armed Forces Health 
Professions Scholarship Program, you should direct 
them to the nearest Naval Recruiting District Office 
where they may secure the appropriate application 
forms. The location of this activity can be found in the 
"white pages" of your local telephone directory. 



Physical Examination 
Before ACDUTRA 

Some confusion persists concerning the physical exami- 
nation that is required before you report for each period 
of active duty for training (ACDUTRA). The exam is re- 
quired regardless of whether ACDUTRA is to be per- 
formed at your school or at a naval facility. 

Because the naval activities that perform these physi- 
cal examinations usually cannot respond to last minute 
requests, you should arrange for your physical exam as 
soon as you receive ACDUTRA orders. If you have al- 
ready had a complete physical examination within 12 
months of the reporting date on your ACDUTRA 
orders, you don't have to get another one provided 
Standard Form 88 and Standard Form 93 from your last 
physical exam are still filed in your health record. But 
you must still report to a naval or Naval Reserve facility 
so a Medical Department representative (usually a 
medical officer) can ascertain that there has been no 
significant change in your condition and that you con- 
tinue to be physically qualified for active duty. Your 
physical fitness will be certified by any entry on Stan- 
dard Form 600 as well as on your ACDUTRA orders. 

Try to obtain a signed copy of SF 88 and SF 93 each 
time you complete a physical examination, so you can 
take advantage of the 12-month provision whenever it 
applies. 



New Hospital Corps Director 

On 17 June, the Navy Hospital Corps will have a 
new director, HMCM Stephen W. Brown. HMCM 
Brown comes to his new post from the Naval Re- 
gional Medical Center, Oakland, where he served 
as Command Master Chief. 

The 27-year Navy veteran has a master's de- 
gree in public administration and is a graduate of 
Hospital Corps School, General Surgery and 
Operating Room School, and Preventive Medicine 
Technician School. 

Master Chief Brown's appointment is an his- 
toric first that breaks with past Navy tradition. 
Never before has a member of the enlisted com- 
munity held a corps directorship. 

Brown sees his appointment as an idea whose 
time has come. The Hospital Corps, manned ex- 
clusively by enlisted personnel, quite logically 
should have a master chief as its director, he says. 

HMCM Brown is not totally surprised by the 
precedent -making decision. There are many other 
recent "firsts," he points out. A supervisory 
course now exists for E-8's and 9's and the odds 
are good, he feels, that E-8's and 9's may soon be 
enrolled in the School of Health Care. 

The new director looks forward to the challenge 
of his job and recognizes that it should have a very 
positive effect on the Hospital Corps. "It clearly 
shows that the opportunity is there. Now the 
senior or master chief out in the field has a job he 
too can shoot for." 




Volume 70, June 1979 



NOTES & ANNOUNCEMENTS 



IN MEMORIAM 

ENS Kathryn M. Bonner, NC, USN (Ret.), a veteran 
of World War I and one of the early members of the 
Navy Nurse Corps, died 6 May 1979 at age 91. She 
graduated from St. Joseph's Hospital School of Nursing 
in Philadelphia, Pa. in 1912 and entered the U.S. Navy 
in 1918. ENS Bonner's duty assignments included ser- 
vice aboard the hospital ship Relief in the early 1920s, 
duty at Naval Hospitals Philadelphia, Pa., Quantico, 
Va., San Diego, Calif., Pensacola, Fla., and American 
Samoa. Her last duty assignment was on the commis- 
sioning crew of the present Naval Hospital Philadel- 
phia. 

ENS Bonner was medically retired in 1935. 

Anthony R. Curreri, M.D., who served as the first 
President of the Uniformed Services University of the 
Health Sciences, died 3 May 1979, in Madison, Wis. at 
age 69. 

Dr. Curreri was born in New York City. He received 
his Bachelor of Arts, Master of Arts, and Doctor of 
Medicine Degrees from the University of Wisconsin. 
He was appointed an instructor in surgery in 1939 and 
advanced to professor in 1953. Dr. Curreri served as 
President of the Uniformed Services University from 
April 1974 to Nov 1976. He was also a member of the 
University's Board of Regents from 1973 to 1974. The 
school was established by Congress in 1972 to train 
physicians for service in the military and the Public 
Health Service. 

Dr. Curreri had returned to the University of Wiscon- 
sin Medical School to resume his position as the Evan 
P. Helfaer Distinguished Professor of Surgery. Dr. 
Curreri was also serving as Associate Director for Edu- 
cation at the William S. Middleton Memorial Veterans 
Administration Hospital in Madison. 



REIMBURSEMENT FOR SPECIALTY 
BOARD EXAMINATIONS 

All Medical Department officers planning to take 
specialty board or similar certifying examinations in 
FY79 are reminded to familiarize themselves with the 
guidelines established in BUMEDINST 1500.4G. 

To be considered for Government reimbursement of 
costs incident to the subject examination (i.e. fees, 
travel, per diem), a request must be submitted to CO, 
HSETC via the appropriate chain of command. 



To receive Government reimbursement, HSETC ap- 
proval must be obtained prior to the date of the exami- 
nation. Requests for HSETC approval should reach 
HSETC at least six weeks before the scheduled date of 
the examination to allow adequate time for processing. 
Requests which are submitted to HSETC after the date 
of the examination, which did not receive prior HSETC 
approval for reimbursement, cannot be acted upon 
favorably. 

NRL-DEVELOPED METHOD ENHANCES 
FAINT PHOTO IMAGES 

A scientist at the Naval Research Laboratory, Wash., 
D.C. has been granted a patent on a technique to 
enhance the contrast of faint photographic images 
through a process involving the photofission of low- 
emergy uranium isotopes. 

NRL's Dr. Kenneth M. Murray, who developed the 
technique, reports it is designed to assist in Defense 
photo reconnaissance and intelligence activities. But, 
he says, it also could be useful in other graphic applica- 
tions, including X-ray activities of medical institutions. 

As an example, Dr. Murray states, if his technique 
was used in medical institutions, the low- level radiation 
that a medical patient receives during X-ray exposures 
might be reduced by as much as 50 percent. 

The NRL researcher's method calls for toning the 
negative for a photograph with a harmless photofission- 
able isotope, irradiating it with energetic X-rays, and 
etching it to bring out extremely faint images im- 
pressed on the film. 

The isotope he uses is uranium 238 which has a very 
low spontaneous fission rate, but can be made to fission 
on demand by irradiating it with high energy X-rays, 

CHAMPUS BENEFITS FOR THE 
TREATMENT OF ALCOHOLISM 

OCHAMPUS and DOD have received several com- 
plaints on the CHAMPUS benefits allowable for 
alcoholism, which essentially are no more than three 
weeks of treatment in-residence (including detoxifica- 
tion), three times in a lifetime. OCHAMPUS set up a 
conference to revise the benefits with current thinking 
and accepted practice in the field. 

Benefits were designed in accordance with the treat- 
ment provided for alcoholism within the military ser- 
vices. The Navy's approach was essentially utilized, as 



s 



U.S. Navy Medicine 



it is generally accepted as the best, and since the Army 
stated it desired to emulate the Navy model. 
Determinations resulting from the conference are: 

• Up to 28 days in-residence treatment will be al- 
lowed, with more if justification is provided. 

• In-residence treatment, utilizing paraprofessional 
counselors will be reimbursed, as long as medical 
"back-up" is available. The half-way house concept, 
much like the Navy's Alcohol Rehabilitation Drydock 
system will also be eligible for reimbursement. 

• Utilization psychotropic drugs for a period longer 
than three days (detoxification only) will be cause for 
audit; justification will be required. 

• Aversion therapy will not be recognized as reim- 
bursible under CHAMPUS. 

• Nonutilization of Alcoholics Anonymous as an 
integral part of the program of therapy offered will be a 
cause for audit. 

The OCHAMPUS conference on alcohol benefits may 
be an historic milestone — it will certainly be emulated 
by the private insurance carriers and Blue Cross/Blue 
Shield. 

MILITARY REFERENCE BOOKS 

The 1979 editions of the popular and useful military 
reference books published by Uniformed Services 
Almanac, Inc. are now available. These handy paper- 
back volumes, filled with the latest, most current infor- 
mation, have been providing detailed compensation 
and benefits information for all military personnel and 
their families for many years and have a well deserved 
reputation for being accurate, timely, and packed with 
important and interesting data. 

The Uniformed Services Almanac for active duty 
members, in its 21st year of publication, again presents 
the unique computerized "take-home" pay tables 
which enable personnel to determine tax and social 
security withholding, as well as basic pay and 
allowance information. All major new developments 
and changes regarding CHAMPUS, Veterans Benefits, 
special pay and bonuses, and many more subjects of 
interest are included. Special sections are devoted to 
insurance, Dependency and Indemnity Compensation 
and Survivors Benefits including the latest SBP 
changes. 

The fifth annual editions of both the National Guard 
Almanac and Reserve Forces Almanac focus on specific 
information prepared for members of these compo- 
nents. Each of these 160-page volumes contain detailed 
information regarding daily, weekend and annual pay, 
comprehensive retirement coverage, promotions, bene- 
fits, organization, and other important subjects. High- 
lighted in this year's editions is complete coverage of 



the new Survivor Benefit Plan for members of the 
Reserve components, and other changes which are of 
interest to all Guard and Reserve members and their 
families. 

The Retired Military Almanac, now in its second year 
of publication, is a very comprehensive compilation of 
information of interest to all retirees and to those who 
are considering retirement. In addition to extensive 
coverage of retired military compensation, this attrac- 
tive volume includes important information about 
health care in military facilities, under CHAMPUS, 
from the VA and USPHS. Other benefits, privileges, 
entitlements, and restrictions are also discussed in 
detail in this valuable reference book. 

Most exchange stores carry these handy books and 
they can also be ordered directly from the publisher. 
Each edition sells for $2.50 (plus 25 cents for postage 
and handling) or $3.50 via first class mail. Special dis- 
counts are available for quantity purchases by units and 
organizations. Requests for information and orders 
should be sent to: Uniformed Services Almanac, P.O. 
Box 76, Wash., D.C. 20044. 



INTERNAL MEDICINE COURSE 

A postgraduate course entitled Update in Internal 
Medicine will be held 27-31 Aug 1979 at the Holiday Inn 
Golden Gateway, 1500 Van Ness Ave., San Francisco, 
Calif. This course consists of half-day sessions devoted 
to the major subspecialties of renal disease, pulmonary, 
cardiology, hematology, neurology, endocrinology, 
gastroenterology, metabolism, infectious disease, and 
rheumatology. 

The tuition fee will be $200, and $175 for interns, 
residents, and fellows with letters of verification. The 
program has been approved for 32 hours of Category I 
credit. 

For further information, contact Robert Siegel, M.D., 
Medical Staff Office, Mills Memorial Hospital, San 
Mateo, Calif. 94401. Telephone (415) 342-5667. 



ATTENTION NAVY AUTHORS 

Many articles by Navy personnel appear each 
year in a variety of professional journals and other 
publications. U.S. Navy Medicine would like to 
include a monthly list of some of these articles 
written by Navy authors from all corps. If you 
have published recently and would like to share 
your research or perceptions with your colleagues, 
please send us the title, name, and issue of the 
publication in which your article appeared. 



Volume 70, June 1979 



INDEPENDENT DUTY - UPDATE 



Gaining Patient Compliance 



CDR Joseph J. Bellanca, MC, USN 



Patient failure to carry out prescribed treatment is a 
familiar story to medical personnel. Patients frequently 
abandon therapy before full benefit has been gained be 
it an exercise program, course of antibiotic, low-back 
treatment, prescribed diet, or long-term antihyperten- 
sive medication. 

It is easy to brush off this situation with the attitude, 
"If the patient doesn't care, it's not my responsibility." 
Unfortunately, this is not what "patient care" is all 
about. Patient care implies caring for the individual and 
showing respect for the person and genuine concern for 
his total welfare. Any problem regarding a patient's 
therapy deserves your immediate attention. If you can 
demonstrate your sincerity and concern for his health 
and are willing to take time to learn how to meet his 
changing needs, you will build the patient's confidence 
in you and your recommendations. 

There are many ways to show genuine interest and 
give the feeling that your patient's needs come First. 

Always treat the patient with genuine respect. He 
takes himself, his family, his work, and his problem 
seriously and he expects you to. 

Listen to his opinions about his health, life, and your 
therapeutic goals. It not only is courtesy, but you can 
learn what he considers to be important and what 
should be emphasized in future visits. Some feature 
you considered irrelevant may actually mean a lot to 
him and other patients like him. 

Take all questions seriously. Be frank in giving ac- 
curate answers in language that is understandable and 
shows that you are interested in satisfying him. Giving 
his problems your personal attention will prove that you 
are interested in his continued satisfaction. 

If appropriate, make a followup call. Certain situa- 
tions may deserve two minutes of your time to phone a 



From the Department of the Navy, Bureau of Medicine and 
Surgery (Code 3142), Washington, D.C. 20372. 

10 



patient and find out how things are going. Several calls 
can be grouped into a planned 10-minute period for 
those situations which require special attention. Your 
patient will be convinced of your interest in his com- 
plete satisfaction. Basically, you are reinforcing the fact 
that he is worthwhile and important, and that he should 
treat himself the same way. 

It is often assumed that the patient will do everything 
you recommend. If you really want full compliance with 
a therapeutic program, you must convince him that you 
offer the best solution to his problem. What many of us 
forget is that conviction and confidence can never be 
separated. We must have confidence in ourselves be- 
fore we can expect the patient to place his confidence in 
us or in what we recommend. Self-confidence, like 
enthusiasm, is contagious. 

One of the most useful ways to get a patient's atten- 
tion and cooperation is to ask questions. Some ques- 
tions are helpful and others are to be avoided since they 
arouse defensiveness and inhibit the patient's ability to 
listen to your recommendations. When you recognize 
this situation, you will avoid such questions as: "How 
are things going at home?" "Have you been taking 
your medication faithfully?" You should avoid certain 
direct questions. Asking an alcoholic how much he 
drinks will seldom elicit a truthful response. Such ques- 
tions arouse guilt and destroy the possibility of building 
an open, honest relationship. Often the same informa- 
tion can be obtained indirectly, or should be discretely 
avoided until it appears that the patient can 
comfortably respond. Useful questions enable the 
patient to identify with your treatment strategy. They 
also encourage the patient to take an active part in 
planning the therapeutic program and help build 
confidence. "Did you know that some of my patients 
have lost 50 pounds in eight months on this same 
diet?" Good questions such as this link the therapy to 
the patient's needs and hopes for success. That's how 
good "patient care" really works. 

U.S. Navy Medicine 



SPRINT: A Psychiatric Contingency 
Response Team in Action 



CDR Thomas G. Carlton, MC, USN 



The survivors of disasters are 
known to have problems that extend 
long after the disaster itself, (i) 
Social, psychiatric, marital, and 
medical problems are all frequent in 
disaster victims. Anxiety, depres- 
sion, inappropriate anger, night- 
mares, marital troubles, declining 
work performance, and multisystem 
medical complaints have been com- 
mon among the survivors of recent 
disasters affecting sea service per 
sonnel. 

Experience with survivors of the 
Belknap-Kennedy collision and the 
1977 Barcelona Harbor liberty 
launch collision has led the psychia- 
trists at the Naval Regional Medical 
Center, Portsmouth, Va. to seek 
ways to prevent serious psychiatric 
sequelae following disasters within 
the Navy community. The Ports- 
mouth psychiatrists have developed 
the Special Psychiatric Rapid Inter- 
vention Team (SPRINT). The 
SPRINT is an organized group of 
mental health personnel, pre- 
trained to provide rapid medical 
mental health support, afloat or 
ashore, immediately subsequent to 
a disaster with the goal of preven- 



CDR Carlton is Assistant Chief of Psychia- 
try for Outpatient Services and Senior Mem- 
ber, Special Psychiatric Rapid Intervention 
Team. NRMC Portsmouth, Va. 23708. 



tion of long-term medical psychiat- 
ric dysfunction or disability. 

In the wake of the 20 Oct 1978 col- 
lision that sank USCGC Cuyahoga 
in Chesapeake Bay, the SPRINT re- 
sponded to a Coast Guard request 
for early preventive mental health 
support. A team of two psychia- 
trists, a clinical psychologist, two 
psychiatric nurses, a psychiatric so- 
cial worker, a psychiatric techni- 
cian, and a hospital chaplain was 

sent to the Coast Guard Reserve 
Training Center, Yorktown, Va., 
shortly after the request was re- 
ceived. At Yorktown, the Cuya- 
hoga's home port, team members 
interviewed the 18 survivors to 
determine needs and to provide 
support for individuals and for the 
crew as a whole. The SPRINT also 
worked with friends, relatives, and 
co-workers of the 1 1 men who were 
lost. 

The SPRINT worked closely with 
the Coast Guard command and 
medical department in a consulta- 
tive role, making the benefits of 
their past experience and special 
training available to those providing 
the leadership and the day-to-day 
medical care for the personnel in- 
volved. The local command was 
enthusiastically supportive of the 
SPRINT'S work. Coast Guard offi- 
cers and petty officers worked 
closely with the SPRINT in seeking 



to prevent adverse sequelae. 

The work of the SPRINT followed 
the basic combat psychiatry princi- 
ples of immediacy, proximity, and 
expectancy. The intervention was 
provided rapidly and "near the 
front." Group cohesion and early 
return to duty were strongly en- 
couraged. 

Preliminary clinical observations 
suggest that the intervention was 
successful. The survivors appear to 
be in much better physical and 
emotional health than would be 
expected based on available litera- 
ture on disaster victims. Of course, 
this impression will require verifica- 
tion by long-term followup. 

The Cuyahoga intervention also 
provided valuable additional ex- 
perience for the SPRINT and dem- 
onstrated its capability for rapid 
contingency response. The impor- 
tance of this capability, widely 
recognized in time of war, has often 
been forgotten in time of peace. The 
SPRINT concept, like that of the 
surgical team, answers one of the 
special needs of Navy medicine and 
provides extraordinary opportuni- 
ties for Navy medical personnel. 



Reference 

1. Edwards JG: Psychiatric aspects of 
civilian disasters. Br Med J l(6015):944-947, 
1976. 



Volume 70, June 1979 



11 




Solar panels are an integral part ofNRMC Camp Lejeune. 



Navy Energy Conservation: Status Report 



Crude oil prices, OPEC, gasoline lines, nuclear power, 
alternative energy sources — all have become inescapa- 
ble topics of daily conversation. With the exception of 
inflation, perhaps no other issue arouses more emotion 
than the energy crisis. Oil heats our homes, feeds our 
industries, powers our transportation, insures our food 
supply, and is essential for national defense. 

It is an inescapable fact of life that solving the energy 
problem is the key to our future. The development of 
alternative sources is one solution. The other is conser- 
vation. 

Navy Energy 

How does the defense establishment in general and 
the Navy in particular fit into the energy picture? 

The Department of Defense uses about 2 percent of 
the nation's total energy resources. The Air Force is the 
single largest user. The Navy ranks second, taking 
about 32 percent of the Defense energy pie. Of that, 72 
percent is petroleum-based fuel. 



During the oil embargo year of 1973, the Navy began 
implementing several conservation programs. By FY77 
Navy energy use had decreased by 27 percent. How- 
ever, 60 percent of this reduction was brought about by 
reducing ship and aircraft strength and by curtailing 
steaming and flight time. 

Navy planners soon realized that further reductions 
would seriously affect the fleet's readiness. Moreover, 
only limited further energy savings would be realized if 
these methods were continued in the future. 

Another problem was inherent in the Navy's shore- 
based facilities. Buildings are not ships. Unused 
vessels can be moored and planes grounded. Function- 
ing offices and hospitals cannot. Therefore, no dramatic 
shoreside savings were forthcoming. 

The answer to future energy savings clearly had to be 
obtained through improvements in energy efficiency 
and the reduction of energy waste, particularly in 
shore-based facilities. 

The July 1977 Executive Order 12003 increased the 



12 



U.S. Navy Medicine 



tempo of the Navy's energy program by plainly stating 
the goal. By 1985 new buildings would have to be 45 
percent more energy efficient than those constructed in 
1975. 

This goal was not a pipe dream. Computer studies 
showed that energy conscious design alone could 
achieve a 38 percent reduction in energy at no addi- 
tional increase in building cost. Everything from simple 
insulation to computerized control and monitoring sys- 
tems would guarantee the remaining 7 percent. 

Weatherstripping and Computer Technology 

To make new buildings and existing structures more 
energy efficient, Navy planners have many tools to 
work with. Design standards are readily available for 
lighting, insulation, windows, siding, efficient mechan- 
ical systems, and buildings. 

In many cases, aesthetics have had to take second 
place to common sense approaches. Gone are the days 
of south-facing picture windows and glass walls. Where 
possible, new structures are oriented on an east-west 
axis to minimize solar heat gain. Such orientation can 



reduce air conditioning requirements by 6 percent. 

Smaller double glazed and coated windows are the 
rule in much new construction as is the liberal use of 
insulation. 

Lighting normally expends about one-fifth of a facil- 
ity's total energy and up to one-third of its electricity. In 
all new construction and in many retrofits of existing 
facilities, high efficiency lighting fixtures are being in- 
stalled as original equipment. 

Heat recovery in mechanical systems is now a pri- 
mary concern. Where before waste heat was vented to 
the outside, it now can be recovered for additional use. 
Cogeneration is one technique being employed. In such 
a system, a gas, diesel, or steam turbine generator 
provides electricity to the facility. Since the power is 
produced on the premises, transmission loss is 
minimal, resulting in high efficiency. Waste exhaust 
heat from the turbine heats boiler water or powers an 
absorption chiller for air conditioning. Typical single 
phase electricity plants generate at about 33 percent 
efficiency. In many cogeneration systems, that effi- 
ciency can double. 



evergreen zoning 







Building orientation and seasonal sun angles are important factors in the design ofQuantico's medical/dental facility. 
Volume 70, June 1979 13 




Energy monitoring and control terminal 



EMCS Concept 



CENTRAL 
CONTROL 

MINI-COMPUTER 



] [ 



REMOTE 
CONTROL 

MICRO-PROCESSOR 




Air Conditioning 



14 



SMALL 
BUILDING 




REMOTE 
CONTROL 

MICRO-PROCESSOR 




J 



9 


f 


t r 

:rr^ 

> 



X 



Thermostat Control 



Heating 



Lighting 



U.S. Navy Medicine 



Computers have provided the answers for energy ef- 
ficient building design. Now they are being used more 
frequently to function as the building's central energy 
brain. Although manual control may seem dependable, 
the human factor often undermines energy efficiency. 
Lights are left on, thermostats wrongly set, and air con- 
ditioners left running. Even with properly adjusted 
thermostats, a great deal of energy can be wasted. Un- 
foreseen variables such as solar heat gain and humidity 
can prevent smooth, efficient operation. 

The energy monitoring and control system (EMCS) is 
the modern and sophisticated solution to energy man- 
agement. Using thermosensors and microprocessors on 
local control or as part of the larger base system, the 
day's heating or cooling requirements can be prepro- 
grammed for maximum efficiency. Timing sequences 
for on-off motor operation and lighting are easily pro- 
grammed as are adjustments for ventilation systems. 

Besides its energy function, an EMCS can be 
programmed to monitor a facility's smoke and fire 
detection, security, and communications systems. Its 
versatility is as limitless as the computer's capacity to 
store information. 

Solar Power 

The Sun, that ultimate energy source, is clean, un- 
limited, and, unfortunately, years away from being 
used as a major energy source. The chief problem is its 
present cost effectiveness. Components and installation 
are still quite expensive and thus far the only practical 
applications have been in domestic hot water systems. 
Nevertheless, the Military Construction Authorization 
bill for FY79 calls for the installation of solar systems in 
all DOD housing and in one-quarter of all military con- 
struction projects. 

More and more Navy facilities are having solar 
systems installed, but as auxiliary systems. In few 
cases will solar power play a major role in achieving the 
1985 goal outlined in the Executive Order. 

Funding 

ECIP. How does the Navy fund its energy conserva- 
tion programs? The introduction of the Energy Conser- 
vation Investment Program (ECIP) in 1975 carefully 
spelled out what funds would be provided for updating 
existing structures and what the money could be used 
for. 

ECIP funds are congressionally authorized and are 
funneled through the Chief of Naval Operations, the 
Naval Facilities Engineering Command (NAVFAC), 
and Military Construction, Navy. To qualify for ECIP 
funds, a facility must justify the project on the basis of 



four criteria. The project must: 

• be a retrofit of an existing facility; 

• cost more than $100,000; 

• be justified on the basis of how much energy is 
saved per $1,000 invested; 

• pay for itself within its lifetime (A new boiler costs 
$50,000 and has a life expectancy of 25 years. The 
savings accrued over that period must add up to the 
initial investment.); and 

• have supporting documentation (NAVFAC Form 
11000/4, DD Form 1391, and an economic analysis. 

Several types of projects qualify for ECIP funds — 
storm windows, insulation, boiler modifications and 
tuneups, solar hot water, energy efficient electrical 
fixtures, heating, ventilation, and air conditioning 
systems, and energy monitoring and control systems. 
All eligible projects must utilize state-of-the-art tech- 
nology. 

EEP. The Energy Engineering Program (EEP) is 
funded by Operational and Maintenance, Navy and is 
designed to identify and develop engineering tech- 
niques that will help achieve the goals of Executive 
Order 12003 and the Navy's energy strategy. EEP pro- 
vides for: 

• feasibility studies to identify high technology, fast 
payback, retrofit projects for existing facilities; 

• the prioritizing and funding of those projects; 

• the development and implementation of a program 
of improved operator/maintenance personnel training; 
and 

• the development and improvement of energy re- 
source management tools for use at the activity level. 

EEP is composed of 11 elements. They are: 

(1) Industrial Energy Conservation 

(2) Cogeneration 

(3) Energy Monitoring and Control Systems 

(4) Industrial/Boiler Water Treatment 

(5) Air Conditioning Tuneup 

(6) Training 

(7) Energy Management Indices 

(8) Energy Distribution System Improvements 

(9) Energy Technology Applications Program 

(10) Heating and Power Plant Optimization 

(11) Alternative Energy Sources 

Elements 2, 3, 5, 8, 9, and 10 involve areas in which 
medical activities can directly participate. 

EEP's Air Conditioning Tuneup element is designed 
to improve the operation and maintenance of air condi- 
tioning systems with a capacity greater than 50 tons. 

(Continued) 



Volume 70, June 1979 



15 



Camp Pendleton — A Retrofit 
Success Story 



One of the most dramatic success stories thus 
far in the Navy's energy conservation campaign is 
NRMC Camp Pendleton. Since 1975 the five-year- 
old, nine-story. 600-bed hospital and medical 
facility has realized a 75 percent reduction in fuel 
oil consumption and a 37 percent overall reduction 
in energy use. 

The success is due in part to a comprehensive 
program based on frequent maintenance, fine 
tuning of equipment, and the installation of auto- 
matic controls and power-saving electrical fix- 
tures. 

Pendleton's computerized maintenance system 
insures that all energy-consuming equipment 
receives the manufacturer's recommended pre- 
ventive maintenance such as periodic lubrication 
and replacement of worn drive belts and filters. 
Other parts are replaced before they begin to 
adversely affect the equipment's operating ef- 
ficiency. 

Fine tuning of boiler controls, air conditioning 
systems, and chillers, have virtually eliminated 
jerky and abrupt equipment response, thus reduc- 
ing fuel consumption and power demand. 

Air conditioning cooling towers have been 
modified, allowing maximum evaporation to take 
place before cooling fans cut in. 

Where possible, clock timers similar to those 
available for home use control simple operations 
such as on-off switching for motors. 

In other areas such as hospital corridors, knife 
switches on lights have dramatically reduced 
power usage. During working hours, minimum 
lighting levels are maintained. After hours, addi- 
tional lights can be turned on for cleaning and 
afterward turned off. In areas where incandescent 



NRMC Camp Pendleton recently won the American Hospi- 
tal Association's Energy Conservation Award for achieving a 
one-year 20 percent energy reduction. 



lighting is not essential, 35-watt fluorescent fix- 
tures are being used. 

The activity's future energy program is very 
ambitious; the goal is to make the facility even 
more energy efficient. The plan for FY80 calls for 
a cogeneration plant, one of the first procured for 
Navy use. Diesel turbine generators will provide 
most of the facility's power. Waste heat from the 
generators will be used to power steam absorption 
air conditioning systems and boilers for domestic 
hot water and other steam requirements. 

Twenty-one air conditioning systems are being 
modified for economizer cycle operation. Such a 
system fully utilizes already cooled internal air 
rather than expending additional energy to cool a 
large volume of outside air. 

Also planned is the application of solar film on 
the inside of existing windows. Such use will 
greatly reduce the absorption of radiant energy 
and could save as much as $89,000 a year. 

Simple and inexpensive methods are also part 
of Pendleton's energy strategy. Where possible, 
thermostats are set at energy efficient levels and 
the temperature of domestic hot water has been 
lowered. 

Staff participation is a key factor in the pro- 
gram. Nurses and housekeeping services keep 
Venetian blinds lowered and turned outward in all 
unoccupied rooms, drastically reducing solar heat 
gain. Other members of the activity, ever 
conscious of the campaign to conserve, do what 
they can to turn off unused lights and appliances. 
All are aware that continuing success in conserva- 
tion is a matter of personal pride. 

The FY80 plan, only a part of which has been 
described, is expected to cut the present energy 
consumption by another 80 percent. Whether that 
figure is achieved or not, one fact remains. NRMC 
Camp Pendleton has already demonstrated what a 
comprehensive retrofit program can do to achieve 
spectacular energy savings. 



16 



U.S. Navy Medicine 




NNMC's "Smart" Energy Monitoring 
and Control System 



Energy conservation was a primary consideration 
in the construction and equipping of both the new 
hospital wing and the new building housing the 
Uniformed Services University of the Health 
Sciences at the National Naval Medical Center. 

The hospital wing was aligned to give it an east- 
west axis, thereby minimizing solar heat gain. In 
patient rooms, the plan called for integral Vene- 
tian blinds sandwiched between small solar 
bronze double-glazed windows. Tinted skylights 
in the other areas let in light while filtering our 
unwanted solar rays. In the lobby and in other 
areas where large windows are required, the 
architects planned overhangs to shade the high 
sun of summer. All entrances have double-doored 
vestibules and the building is completely insu- 
lated. 

Energy conscious design is only the foundation 
of NNMC's conservation effort. The real energy 
saver is the sophisticated computer based brain. 
CBAS, the Central Building Automation System, 
utilizes analog and digital sensors to control and 
monitor the wing's heating, ventilation, air condi- 
tioning, hot and chilled water, steam, electrical 



power and lighting, and emergency power 
generation. The specific energy-related functions 
the computer will perform are: 

• Sequenced on-off motor control 

• Ventilation damper adjustment 

• Recording and forecasting of trend load 
buildup that allows manual control of peak loads 

• Electrical energy totalizing 

• Exterior lighting control 

• Energy metering 

• Heat reclamation 

• Monitoring of total energy usage 

The CBAS computer can and will do more than 
monitor and control energy. Because energy 
management requires only a small percentage of 
the computer's total capacity, it can also accom- 
modate other systems as well — medical gases, 
fire alarm and smoke management, security, and 
a sophisticated zone paging system. 

Even with the addition of these other chores, 
the central computer, in conjunction with add-on 
terminals and microprocessors, has the potential 
to take on many more jobs in the future. 



Volume 70, June 1979 



17 



NAVFAC's Engineering Field Divisions are currently 
identifying and surveying all activities having systems 
of this capacity. If your activity has an air conditioning 
system over 50 tons and you have not been contacted by 
an Engineering Field Division representative, you 
should contact NAVFAC for a survey. 

The Energy Distribution System Improvement ele- 
ment is designed to evaluate an activity's heating and 
electrical distribution system and gauge its potential for 
improvement. NAVFAC Engineering Field Divisions 
are conducting surveys for this element. All activities 
should see that their systems are evaluated for energy 
efficiency. 

The Heating and Power Plant Optimization element 
is aimed at improving efficiencies of large (over 50 
MBTU's per hr.) central steam and electric plants by: 

• upgrading equipment; 

• identifying staffing, maintenance, and training 
deficiencies; 

• improving operational procedures; and 

• developing ECIP/ETAP projects. 

NAVFAC Engineering Field Divisions are also co- 
ordinating surveys relating to this program element. 



Medical or other activities without staff civil en- 
gineers or public works officers should contact the local 
public works liaison officer to see how these program 
elements apply to their commands. Special inquiry 
should be made to determine whether the Engineering 
Field Division conducted the necessary engineering 
surveys. 

ETAP. The Energy Technology Application Program 
(ETAP) is another program funded by congressional 
appropriation. It is administered under the EEP pro- 
gram by NAVFAC. Similar to ECIP, ETAP funds apply 
solely to retrofits. Projects must: 

• range between $5,000 and $100,000 including 
design cost; 

• save at least 20 MBTU's annually per $1,000 in- 
vested; 

• be life cycle cost effective; and 

• have supporting documentation (Special Project 
step 2 submission and economic analysis). 

Projects qualifying for ETAP funds are exactly the 
same as for ECIP but must cost less than $100,000. 

As with ECIP, all eligible projects must utilize state- 
of-the-art technology. 




Solar pond array at the Naval Weapons Center dispensary and dental clime, China Lake, Calif., is part of a system designed 
to provide 90 percent of the facility's domestic hot water, 61 percent of the space heating, and 63 percent of the space cooling 
requirements. 



18 



U.S. Navy Medicine 



The BUMED Energy Effort 

Although the Navy has realized a 27 percent reduc- 
tion in Energy consumption since 1973, energy con- 
sumption at BUMED activities has increased by 6.5 
percent. Since 1977 there has been a greater effort to 
retrofit existing facilities and take advantage of energy 
efficient design and equipment in the construction of 
new buildings. 

Using ECIP and ETAP funds, BUMED is currently 
retrofitting over a dozen facilities with everything from 
storm windows and insulation to energy monitoring and 
control systems. NRMC Camp Pendleton will shortly 
install a diesel turbine power cogeneration air condi- 
tioning system, and update and tune several of its 
boilers. 

Installation of solar panels for domestic hot water for 
the Cecil Field dispensary and dental clinic is now 
operational. 

The Future 

What does the future hold for Navy energy conserva- 
tion? The nation's demand for energy increases daily as 
does our dependency on foreign oil. The armed forces 
too are becoming more vulnerable to shortfalls and sky- 
rocketing costs. Little chance exists that a major energy 
breakthrough is about to occur. Nuclear energy is under 
attack and major applications of solar technology yet 
seem far off. The ability of the Navy and her sister 
services to continue to fulfill their obligations depends 
to a large degree on their own efforts to reduce con- 
sumption of petroleum. 

The Navy, not alone as a "late starter," is now hard 
at work to make up for lost time. Besides conservation 
funding programs, other initiatives are underway. 
Since 1966, a course on energy management has been 
held annually, sponsored by the Naval School, Civil 
Engineer Corps Officers, Port Hueneme. This year the 
week-long event, held in Washington, attracted 120 
participants, about double last year's attendance. Navy 
and civilian energy specialists lectured on state-of-the- 
art developments and instructed the participants in 
practical energy problem-solving. 

To promote competitive interest among Navy 
activities, the Secretary of the Navy now sponsors a 
Navy-wide Energy Conservation Award. With Large 
Shore and Small Shore Activities as two of the cate- 
gories, the competition centers around five functional 
areas. 

• Awareness of and compliance with existing 
directive issuances in the field of energy resource 
management. 

• Planning in the areas of energy conservation and 



Pending BUMED Retrofit Projects 


Camp Pendleton 


• Building Alterations 


Norfolk 


• Heat Recovery System 


Quantico 


• Insulation and Storm Win- 
dows 

• Thermostat Control Values 

• Boiler Replacement 


Philadelphia 


■ Installation of Day/Night 

Thermostats 
• Storm Windows 


Bethesda 


• Building Insulation 


Corpus Christi 


• Energy Monitoring and 
Control System 


Great Lakes 


• Building Alterations 


Millington (Memphis) 


• Refrigeration Unit for Sur- 
gical Suite 


San Diego 


• Heat Recovery System for 
Laundry Building 


NAS Jacksonville 


• Installation of Vestibules 
and Air Curtains 

• Modification of Air Condi- 
tioning Units in Bldg. 1010 

• Cooling Tower Chemical 
Treatment 



use of less depleting, more available energy sources. 

• Efficient use and maintenance of all energy con- 
suming, producing, and distributing equipment. 

• Innovative proposals for the improvement of exist- 
ing equipment, or the design and development of a new 
process or unit to solve specific problems of energy 
production, utilization, distribution. 

• Training of personnel in specific duties and re- 
sponsibilities related to energy conservation as well as 
awareness of the command's specific problems in 
energy conservation. 

The winner of this year's Large Shore Activity award 
is NAS Patuxent River. The Small Shore Activity award 
went to BUMED's NRMC Corpus Christi. 

Very little has been accomplished compared to what 
remains to be done. Clearly, more courses are required 
to acquaint Navy energy managers both with new tech- 
nology and retrofit techniques applicable to their own 



Volume 70, June 1979 



19 



facilities. More needs to be done to acquaint them with 
ECIP, ETAP, and other programs. Thus far few med- 
ical/dental facilities have applied for funds through 
these programs. 

Camp Pendleton and NRMC Corpus Christi provide 
excellent examples that medical facilities can be energy 
efficient. Activities that aggressively pursue the fund- 
ing of energy conservation projects will quickly see the 
savings reflected in their monthly energy bills. This in 
turn will free funds for purchasing much needed medi- 
cal supplies and equipment. 

Awareness and dedication are the keys to the long- 
term success of the Navy's energy conservation effort. 
The technology is available. The big job of applying it 
remains to be done. — JKH 



For further information or to contact your NAVFAC 
Engineering Field Division about a survey: 



Northern Division 
Philadelphia, PA 
(215) 755-3995 
Autovon 443-3995 

Chesapeake Division 
Washington, DC 
(202) 443-3765 
Autovon 288-3765 

Atlantic Division 
Norfolk, VA 
(804) 444-7331 
Autovon 690-7331 



Southern Division 
Charleston, SC 
(803) 743-3870 
Autovon 794-3870 

Western Division 
San Bruno, CA 
(415) 877-7506 
Autovon 859-7506 

Pacific Division 
Pearl Harbor, HI 

(808) 471-3214 

Autovon Call Local Operator 



Energy Glossary 



ACT-UP Maintenance, 

Air Conditioning Tuneup Program (part of EEP). $100,000. 



Navy, and costing less than 



Cogeneration 

Method of improving energy consuming machin- 
ery efficiencies by using waste heat from a pri- 
mary source to power a secondary machine, i.e. 
waste heat from power generating equipment to 
power steam absorption air conditioning equip- 
ment and heat domestic hot water. 



HVAC 

Heating, ventilation, and air conditioning system. 

Low Energy Structures 

Buildings that have been designed with orienta- 
tion and architectural and structural features that 
minimize energy consumption. 



EOP 

Energy Conservation Investment Program. Ener- 
gy saving projects funded by Military Construc- 
tion, Navy and exceeding $100,000. 

EFD 

Engineering Field Divisions of the Naval Facilities 
Engineering Command. There are six regional 
divisions. 

EMCS 

Energy monitoring and control system. Uses auto- 
mated equipment, usually computers, to monitor 
and control energy consuming systems. 



MBTU 

Millions of British Thermal Units. Standard ener- 
gy unit used by the Navy. 

MILCON 

Military Construction, Navy. Supplies funds for 
new construction. 

NAVFAC 

Naval Facilities Engineering Command. 

O&MN 

Operations and Maintenance, Navy. Funds daily 
operations. 



ETAP 

Energy Technology Applications Program. Ener- 
gy saving projects funded by Operations and 



Retrofit 

Installation of new energy saving equipment and/ 
or the upgrading of an existing structure. 



20 



U.S. Navy Medicine 



Fine Tuning and Basic Repair Net 
Institution 20% Energy Cut 



Institutional administrators, bombarded 
by reports touting that energy consump- 
tion can be substantially reduced simply 
by Fine tuning their facility, can take 
heart. These reports can be true. 
Mamaroneck High School (Mamaroneck, 
N.Y.) serves as a classic case history. 

The 322.000 square foot facility, con- 
sisting of a relatively new wing connect- 
ing two 50-year-oid buildings, has a poor 
energy record. During a normal winter 
(4,848 degree days is normal for the 
area), it used approximately 320,000 
gallons of oil and 1.6 million kwh of elec- 
tricity. 

The institution consumed an average of 
194,700 BTU's per square foot, which is 
high for that type of facility. 

An energy/reduction, conservation and 
management program (E/ECM) at the 
school was launched nearly three years 
ago and is now netting a 20% reduction in 
energy consumption, with predictions of 
obtaining as much as a 50% cutback 
viewed as reasonable. 

The E/RCM program was divided into 
three major phases. 

• Survey the buildings for energy 
problems; 

• Bring the facility's existing systems 
into the best possible working order; 

• Institute improvements in the insti- 
tution's mechanical and electrical sys- 
tems. 

The E/RCM program saved S47.000 in 
the first year alone. If current predictions 
are correct, the district will be repaid for 
its investment in four to six years, and 
then banks its savings in the years after 
that. 

"Our investment in this project was 



approximately $200,000," said Paul Mc- 
Devitt, assistant superintendent for the 
district's business affairs. "I consider 
that a moderate investment compared to 
the energy savings we've been able to 
achieve," 

Mamaroneck High School's E/RCM 
program boasts common sense fine ton- 
ing as opposed to sophisticated "new 
technology." The following chronicles 
the school's actions. 

* Ancient, defective thermostats and 
temperature control valves were replaced 
or rebuilt throughout the buildings. 
Where radiators had no controls (about 
30% of them), new thermostats were in- 
stalled. 

* Buried boiler condensate return lines 
had completely corroded. As a result, 
boilers were constantly calling for make- 
up water. Cost of added water, extra fuel 
to heat and chemicals to treat it was esti- 
mated to be more than $100,000 over a 
10-year period. 

Full extent of this problem was not dis- 
covered until water meters were installed 
on water feeds to each boiler. 

New condensate lines were installed to 
solve the problem. 

• Six inches of fiberglass insulation 
was laid in the school's attics. This work 
was accomplished by district personnel 
and summer student help, cutting labor 
costs considerably. 

• The gymnasium had contained 64 
incandescent lighting fixtures, each with 
a 500 watt bulb. These were replaced by 
eight 1,000 watt high pressure sodium 
vapor fixtures. The change improved 
lighting and cut by one-quarter the sys- 
tem's energy consumption. 



Mamaroneck High School: 


the 


figures tell the story 




1974-75 




1977-78 


Redaction 


Fuel Oil 316,500 gal. 




249,000 gal. 


21% 


Electricity 1 . 6 million kwh 




1.32 million kwh 


18% 


BTU's/ square foot 194,700 




154,700 


20% 



Dollar savings for the lighting conver- 
sion at today's rates are estimated at over 
53,000 annually. Additional savings will 
come in labor and bulb replacement 
costs, since the lights will last 15 to 20 
times longer than the ones they replaced. 

• All incandescent fixtures were re- 
placed with fluorescent units, saving 
energy and labor costs. 

In corridors, phantom tubes were used 
to cut energy use approximately in half, 
but with the ability to provide even and 
pleasant light. 

• Continuously running showers were 
a major source of energy waste. Metering 
type faucets were specified to control 
water flow. At the same time, water 
temperatures were reduced from 140° to 
105° F saving fuels and creating a safer 
environment. 

• Three, 50-year-old boilers were 
tested and found to be sound. However, a 
highly efficient air atomizing burner was 
installed in one of the boilers. 

Now, this 80% efficient boiler-burner 
unit is being used as a "workhorse" 
heating unit, carrying the entire Joad of 
the buildings, doing the same job that the 
three units had been accomplishing in the 
past. 

The two other units are only used for 
standby, eliminating the need to invest 
money in revamping them. 

McDevitt emphasized that the school's 
energy savings have been accomplished 
without "touching the very structure of 
the building." But he doesn't rule out 
that possibility. 

"We're going to take a hard look at 
other options that could involve major 
structural renovation. But we'll have to 
be careful," he added. "We could wind 
up spending a lot of money and not 
getting much back in return." 

AMS Technical Group, Inc. (Mamaro- 
neck) served as consulting engineers for 
the E/RCM project. 

— Reprinted from Institutional Man- 
agement, March 1979. North American 
Publishing Co. 



Volume 70, June 1979 



21 



PROFESSIONAL 



Pulmonary Function Testing in the Navy 
Asbestos Medical Monitoring Program 



LCDR Sally K. Cowles, MC, USN 



Pulmonary function testing is one of the key exami- 
nation items in the asbestos medical monitoring pro- 
gram. When properly performed with well calibrated 
instruments, pulmonary function testing can detect 
lung changes before chest X-ray evidence appears and 
before clinical symptoms become apparent. 

There is no single pulmonary function abnormality, 
chest X-ray finding, or physical examination finding 
uniquely specific for asbestos-related disease. How- 
ever, certain findings, taken together with a history of 
exposure to asbestos should arouse a high level of sus- 
picion that asbestos-related disease exists. Pulmonary 
function results are nonspecific; findings similar to 
those seen in asbestos-related disease are also seen in 
persons with many other lung problems, including 
heavy smoking. 

Of the wide variety of pulmonary function tests avail- 
able, only a few are of current usefulness for an 
asbestos medical monitoring program. To be a useful 
screening test, a test must be simple to perform and 
administer, readily reproducible, have known general 
population standards, and it must be shown to be able 
to discriminate reliably between those who have a high 
likelihood of disease and those who do not. To detect 
early changes of restrictive lung disease seen with the 
fibrotic changes of asbestosis, forced expiration spi- 
rometry results come closest to meeting these screen- 
ing criteria. Other tests may be more sensitive, but they 



From NRMC Bremerton. Wash. 98314. 



are also less reproducible, more cumbersome to ad- 
minister, or lack reliable general population standards. 

Spirometry Tests 

The test values obtained from a forced expiration 
maneuver on a reliable spirometer include the following 
two tests required by the asbestos medical monitoring 
program. 

FVC (Forced Vital Capacity). The FVC is the maximal 
volume of air which can be exhaled forcefully after a 
maximal inspiration. It is perhaps the most sensitive 
indicator of early asbestos-related disease. The lung 
fibrosis seen in asbestosis results in an increased "stiff- 
ness" of the lung and decrease in lung volume. Other 
causes of a reduced FVC include lung fibrosis of non- 
asbestos etiology (Silicosis, berylliosis, rheumatoid 
lung), replacement of lung tissue by tumor or inflam- 
matory exudate (such as in TB, pneumonia), chest wall 
deformities, and severe bronchopulmonary disease 
(advanced obstructive lung disease). 

FEVj (Forced Expiratory Volume in One Second). 
The FEVf is the volume of air which can be forcibly 
expelled during the first second of expiration. The 
FEVi is abnormal in obstructive lung disease and pro- 
vides a method to help distinguish restrictive lung dis- 
ease (such as that seen in asbestos-related disease) 
from obstructive lung disease (seen more frequently in 
smoking-related diseases such as emphysema and 
chronic bronchitis). 

By calculating the FEVj as a percent of FVC, further 
definition of the type of impairment can be obtained. 
Normally, one should be able to expire 70-80% of the 
FVC in one second, depending on age and sex. In an 



U.S. Navy Medicine 



individual with pulmonary fibrosis (such as in asbesto- 
sis), the FVC may be significantly reduced, and in turn, 
because of the decreased volume, the FEVj will also be 
reduced when compared to expected normal values; 
but, in the absence of obstructive disease, one should 
expire 80% of this reduced vital capacity in one second 
(i.e. FEVi -*■ FVC x 100% = 80% or greater). If on the 
other hand, obstructive lung disease is present (i.e. 
emphysema, chronic bronchitis), both the FEVi as per- 
cent of predicted normal value, and the FEVj as per- 
cent of FVC will be abnormally low. 

Techniques of Spirometry 

Technical Manual 77-1 Pulmonary Function Testing 
in Occupational Medicine, developed by Dr. Horvath 
for pulmonary function technician training and avail- 
able from Navy Environmental Health Center, Cincin- 
nati, Ohio, is an excellent reference for proper pulmo- 
nary function techniques; much of this paper has been 
developed from it. 

The single most important factor in successful spi- 
rometry is the skill and training of the technician. 
Technician training for the asbestos medical monitoring 
program will be made available by the Navy Environ- 
mental Health Center. During the actual performance 
of spirometry, meticulous attention to detail is essen- 




Chest film demonstrates advanced asbestosis with pleural 
thickening and calcification. Interstitial disease particularly 
prominent in the lower lung zones and "shaggy" heart. 



tial. The procedure should be explained to the worker in 
simple terms. At least one hour should have elapsed 
since the subject's last smoke. Pulmonary function 
studies should not be performed within two hours after 
the main meal. They should be postponed if the worker 
is acutely ill from any cause or has experienced an 
upper or lower respiratory tract infection within the 
previous three weeks. Tight clothing should be 
loosened, dentures removed. The worker should sit or 
stand in front of the spirometer with the chin slightly 
elevated and the neck slightly extended. Under normal 
circumstances there is little difference in spirometry 
values whether the subject is sitting or standing. An 
exception is in the grossly obese subject where the 
sitting value may be significantly lower. The use of a 
nose clip is recommended. 

The worker should then be instructed to take the 
deepest possible breath, to close his mouth firmly 
around the mouthpiece and to blow immediately into 
the machine as hard, as fast, and as completely as pos- 
sible. The most common errors at this point include 
failing to keep a tight seal around the mouthpiece, 
pursing the lips as if blowing a trumpet, or obstructing 
the mouthpiece with the tongue. 

After two practice blows, three further tracings 
should be obtained and checked for acceptability. At- 






Prominent interstitial disease with linear, irregular opacities. 



Volume 70, June 1979 



23 



tempts made without full inspiration prior to expiration, 
without maximal effort, or which are marred by cough- 
ing should be repeated. The variation between the 
largest and the smallest forced vital capacity (FVC) of 
the three satisfactory tracings should not exceed 10%. 
From the three satisfactory tracings, the FVC and FEV] 
should be measured. The largest FVC and FEVi should 
be used regardless of the satisfactory curve(s) on which 
they occur. For example, in the calculation of FEVj -&■ 
FVC x 100%, the FEV] and FVC need not be from the 
same curve. 

Correction to BTPS (body temperature, ambient 
pressure, saturated with water vapor) is an important 
step in the calculation of spirometric tests. Correction is 
necessary because the patient exhales the gas at body 
temperature (37°C) while the volume recorded by the 
spirometer is at the somewhat lower ambient tempera- 
ture. This volume of gas recorded by the spirometer 
must then be multiplied by a factor to convert it to what 
it should be at normal body temperature. This usually 
increases the gas volume recorded by the spirometer by 
approximately 8%, but it may vary from 4-10% de- 
pending upon ambient temperature. This correction is 
particularly important in areas where ambient tempera- 
ture varies considerably. Some manufacturers (includ- 
ing Jones, makers of Jones Pulmonor II) build in an 
automatic correction factor. This is acceptable, but if 
ambient temperature in the room in which spirometry is 
performed varies more than a few degrees, correction 
to BTPS may still be necessary. 

Evaluation of Results 

The decision whether baseline spirometry results are 
"normal" is usually made by comparison with a set of 
published predicted normal values. Those of Morris 
and co-workers published in 1971 in the American 
Review of Respiratory Disease, were derived from a 
population of healthy, nonsmoking men and women 
with relatively little exposure to air pollution. They are 
regarded by many as the preferred set of predicted 
normals. 

Abnormal functions are present when the: 

• FEVi or FVC is less than 80% of predicted; or 

• FEVi ■* FVC x 100% is less than 70%. 

It must be pointed out that the FVC and FEVi of non- 
caucasians is approximately 15% lower than in whites 
of the same age and height. In noncaucasians (black, 
orientals), the predicted FEVj and FVC for any given 
individual should be multiplied by 0.85 to adjust for this 
15% difference. No such correction is necessary for the 
FEV! 4- FVC x 100%. Before labeling any baseline 
study as abnormal, it should be repeated in two weeks. 

After a baseline has been established, subsequent 



pulmonary function tests on an individual worker 
should be compared with his previous best values, not a 
set of predicted normals. The worker serves as his own 
control and followup values can be compared to 
changes in pulmonary function which might normally 
be expected with aging. In males, a 30 milliliter annual 
decline in FEV i and 25 milliliters in FVC can be at- 
tributed to normal aging. In females, a 25 milliliter 
decline in both FEVi an< ^ FVC is expected per year. In 
addition, the change in any given subject tested over a 
period of time may be 2-6% for the FEVi and the FVC. 
This variation includes both biological and instrumen- 
tation factors. Comparing followup values obtained on 
different spirometers can be an additional source of 
error. Measurements of pulmonary function are highest 
in the afternoon and decline slightly during the evening 
hours. Values are also higher in the summer than in the 
winter. Annual followups should ideally be scheduled 
during the same shift and month. The effects on air- 
ways of cigarette smoking may be particularly pro- 
nounced up to an hour after smoking. 

Considering all the above sources of variation, follow- 
up studies should be compared to the previous highest 
value for each test, and if the changes seen are not 
clearly attributable to the effects of nondisease related 
variables, they should be considered abnormal when (1) 
there is a decline of more than 8% in the FEVi or tne 
FVC; (2) when the decrease in the FEVi "*" Fvc x 
100% is greater than 6%; or (3) the FEVi + FVC x 
100% is less than 70% at any time. Any abnormalities 
should be verified by repeating spirometry in two 
weeks. If abnormalities persist, clinical assessment by 
a physician qualified to evaluate chest disease is essen- 
tial. Spirometric findings of severe respiratory impair- 
ment, defined by the proposed asbestos instruction 
OPNAVINST 6260.1 A as an FEVi -5- FVC x 100% less 
than 45% or an FVC of less than 50% of predicted is 
considered disqualifying for asbestos exposure. A 
worker with deteriorating pulmonary function tests 
should be fully evaluated prior to reaching such a 
degree of impairment, however. 

Choice of Spirometer' 

No single instrument is currently being recom- 
mended by the Navy as the instrument of choice for 
pulmonary function testing in the asbestos medical 
surveillance program. However, it is essential that the 
machine be a volume displacement spirometer which 
reliably retains calibration, can be periodically checked 
for calibration, is reasonably simple to operate, and 
which is well maintained. Reliable instruments which 
may be successfully used include the Stead-Wells and 
Collins water-seal spirometers, bellows spirometers 



j,t 



U.S. Navy Medicine 




Examinee exhales forcefully into spirometer mouthpiece for measurement of lung volume (FVC) and the capacity of airways to 
accommodate rapid exhalation {FEVi). 



such as the Vitalograph or Jones Pulmonor, or a dry 
rolling seal spirometer such as one of Ohio Medical or 
Collins. Most Navy shipyards currently use the Jones 
Pulmonor bellows type spirometer or the Ohio Medical 
dry rolling seal type. 

Whatever the machine, it should be regularly 
checked for calibration. Calibration should be per- 
formed at least weekly with a calibration syringe of at 
least 2 liters volume. Flow rates can also be checked by 
hooking up a peak flow meter in series between the 
syringe and spirometer. If possible, quarterly calibra- 
tion against a Stead-Wells or Collins water-seal spi- 
rometer is also recommended. Because of the degree of 
day-to-day biologic variation in spirometry values, 
biologic calibration is only useful as a rough check on 
general machine functioning, and is not a reliable guide 



to precise calibration. However, it is a simple and quick 
way to confirm a major dysfunction if one is suspected . 

Each spirometer needs regular preventive mainte- 
nance. Care and cleaning methods will vary from 
machine to machine, but if results are to be accurate 
(especially when results are compared from year to 
year), daily cleaning and maintenance must be per- 
formed religiously. Most spirometers are durable and 
long-lived instruments, but they are also precision 
machines which must be treated with the care and at- 
tention necessary to keep them in good operating order 
and accurate calibration. 

The validity and reliability of spirometry results in 
the end depend entirely on the ability of the spirometry 
technician and the maintenance and calibration of the 
spirometer. 



Volume 70, June 1979 



25 



Screening of Alcoholism 



LT Raymond N. Sampson, MSC, USN 



One of the common screening instruments used in the 
Navy to identify alcohol abusers is the Twenty Ques- 
tions test. It requires the respondent to answer either 
"yes" or "no" to each of 20 questions thought to be 
predictive of alcoholism. The Twenty Questions test 
is not copyrighted; consequently it is reproduced here. 
Table I lists those questions. Currently the instrument 
has no known published norms and is subjectively used 
as a clinical judgment tool. The physician, psycholo- 
gist, or alcohol rehabilitation professional arbitrarily 
decides which items are most predictive of alcoholism 
and how many "yes" responses are required before the 
respondent is assigned to an alcohol rehabilitation pro- 
gram. 

Over the last three years the author has interviewed 
professionals working in various Navy alcohol treat- 
ment facilities in Maine, California, and Hawaii. They 
were asked how they use the Twenty Questions score 
when deciding whether a patient should be referred to a 
Navy alcohol treatment program. Some of the following 
replies dramatically illustrate how varied are the 
criteria for assignment to a Navy alcohol treatment 
facility. 

"The alcoholic's denial system is so great that you 
cannot trust him to be honest when responding to the 
questions. The number of questions he (the alcoholic) 
checks yes ' will probably be about the same as the 
nonalcoholic. " 

"If he (the alcoholic) was honest, he'd probably 
check all of the questions 'yes. '" 

"Anybody who say he's had a complete loss of 
memory as a result of drinking {item 17) is an alco- 
holic. 

' 'The longer a guy has been In the Navy, the more 
alcohol indicators you'll find and the greater the likeli- 
hood he'll need alcohol treatment. " 

The present study sought to answer the following 
questions: 

• Is the Twenty Questions test useful in distinguish- 



LT Sampson is assigned to the Mental Health Clinic NRMC, Pearl 
Harbor, Hawaii. 



ing problem drinkers who need to be assigned to an 
alcohol treatment program from others in the Navy not 
in need of alcohol treatment? 

• What questions, if any, do a good job of predicting 
whether a patient is in need of an alcohol treatment 
program? 

• Is the person with many years of active duty ser- 
vice time more likely to be in need of alcohol treatment 
than one with less service time? 



Method 

Five hundred sixteen subjects, who took the Twenty 
Questions test in 1978 and were subsequently inter- 
viewed and admitted to the Alcohol Rehabilitation Dry- 
dock (ARD) in Pearl Harbor, Hawaii, were randomly 
selected and served as the experimental group. The 
average age of the experimental group was 25.77 years. 
Standard deviation was 9.51 years. Thirteen were 
females and 503 were males. Only three of the subjects 
were officers. 

Four hundred subjects who received the Twenty 
Questions test in 1978 and who were not subsequently 
admitted to any alcohol rehabilitation program were 
randomly selected from the Pearl Harbor Mental 
Health Clinic files and served as the control group. The 
average age of the control group was 22.56 years. The 
standard deviation was 4.90 years. Forty-nine were 
females; 351 were males. Fifteen subjects in the control 
group were officers. 



Results 

In order to determine whether the Twenty Questions 
test distinguished problem drinkers requiring an alco- 
hol treatment program from others, the study required 
the means and standard deviations of the scores (num- 
ber of questions checked "yes") for the control and ex- 
perimental groups. The average number of questions 
marked "yes" for the control group was 1.49. Standard 
deviation was 2.10. The average number of questions 
marked "yes" for the experimental group was 8.05. 



26 



U.S. Navy Medicine 









TABLE 1 












Yes 


No 






Yes 


No 


1. 


Do you lose time from work due to 






11. 


Do you have a drink the next morn- 








drinking? 


D 


□ 




ing? 


□ 


□ 


2. 


Is drinking making your home life 






12. 


Does drinking cause you to have diffi- 








unhappy? 


□ 


D 




culty in sleeping? 


□ 


□ 


3. 


Do you drink because you are shy 






13. 


Has your efficiency decreased since 








with others? 


a 


□ 




drinking? 


D 


D 


4. 


Is drinking affecting your reputation? 


a 


□ 


14. 


Is drinking jeopardizing your job or 
business? 


□ 


D 


5. 


Have you ever felt guilty after drink- 
















ing? 


a 


a 


15. 


Do you drink to escape from worries 
or troubles? 





□ 


6. 


Have you gotten into financial diff i- 
















culties as a result of drinking? 


a 


D 


16. 


Do you drink alone? 


□ 


□ 


7. 


Does your drinking make you care- 






17. 


Have you ever had a complete loss of 








less of your family's welfare? 


a 


a 




memory as a result of drinking? 


□ 


D 


8. 


Do you turn to lower companions and 






18. 


Has your physician ever treated you 








an inferior environment when drink- 








for drinking? 


□ 


□ 




ing? 


D 


a 


19. 


Do you drink to build up your self- 






9. 


Has your ambition decreased since 
drinking? 


a 


a 


20. 


confidence? 

Have you ever been to a hospital or 


p 


P 


10. 


Do you crave a drink at a definite 
time daily? 


□ 


□ 




institution on account of drinking? 


□ 


□ 



Standard deviation was 5.57. The t test comparing con- 
trol group and experimental group scores was statisti- 
cally significant (t = 22.62; p<.005) and strongly sug- 
gested that the Twenty Questions test does a good job 
of discriminating between those in need of an alcohol 
treatment program, such as an ARD, and those not re- 
quiring treatment. 

Table 2 lists the proportion of subjects in the control 
and experimental groups who responded to each item. 

In order to determine which questions best predicted 
alcoholism, a point-biserial correlation was obtained on 
each question responded to by the experimental group. 
Table 3 lists the correlation, t value, and significance 
level for each item. Every question of the Twenty 
Questions test was statistically significant beyond the 
.001 level of significance, strongly suggesting that each 
question does an excellent job of predicting alcoholism. 



A Pearson product moment correlation (r) was ap- 
plied to the data in order to determine whether number 
of years in military service was positively correlated to 
the number of questions answered "yes" on the 
Twenty Questions test. The correlation was not statisti- 
cally significant (r=.07). A subject with many years of 
active duty service was no more likely to need alcohol 
treatment than a subject having less active duty service 
time. 

Discussion 

Anyone who has ever confronted an alcoholic about 
his drinking is well aware of the alcoholic's defensive- 
ness. Yet when an individual needing an alcohol reha- 
bilitation program is screened for alcohol problems with 
the Twenty Questions test, he willingly responds "yes" 



Volume 70, June 1979 



27 





TABLE 2 




Question 


Proportion of 
Control Group 
Answering "yes" 
to Question 


Proportion of 
Experimental Group 
Answering "yes" 
to Question 


1 


.02 


.39 


2 


.02 


.43 


3 


.08 


.27 


4 


.03 


.58 


5 


.20 


.56 


6 


.06 


.43 


7 


.03 


.34 


8 


.07 


.31 


9 


.04 


.44 


10 


.03 


.31 


11 


.03 


.35 


12 


.03 


.24 


13 


.02 


.46 


14 


.01 


.48 


15 


.26 


.58 


16 


.27 


.58 


17 


.19 


.57 


18 





.16 


19 


.09 


.34 


20 





.22 







TABLE 3 




Question 


Tpb 


t 


Significance 
Level 


1 


.63 


18.30 




2 


.60 


17.00 




3 


.56 


15.29 




4 


.59 


16.50 




5 


.60 


17.00 




6 


.63 


18.30 




7 


.66 


19.95 




8 


.70 


22.35 




9 


.65 


19.39 




10 


.54 


14.57 




11 


.60 


17.00 




12 


.62 


18.01 




13 


.67 


20.53 




14 


.62 


18.01 




15 


.58 


16.23 




16 


.53 


14.13 




17 


.53 


14.13 




18 


.50 


13.02 




19 


.61 


17.51 


* 


20 


.46 


11.71 




*p<.001 









to an average of eight of the questions. Ninety-nine 
point nine percent of those not in need of an alcohol re- 
habilitation program respond "yes" to fewer than eight 
questions. The average number of "yes" responses for 
the control group was only 1.49. 

The subjects with alcohol problems in this experi- 
ment took the Twenty Questions test before they had 
ever been accepted into a rehabilitation program. 
Future research might investigate the Twenty Ques- 
tions test score of alcoholics before and after treatment 
to determine whether there is a significant change in 
their scores on that self-report instrument. 

All questions seem to do a good job of predicting 
alcohol problems serious enough to warrant treatment. 
That is not overly surprising. For example, none of the 
control group reported ever being hospitalized or 
placed in an institution because of drinking. Only one 
percent of the control group reported that drinking was 
jeopardizing their jobs. What is surprising is that one 
percent of the control group reported that drinking was 



jeopardizing their jobs and yet received no treatment 
through some alcohol rehabilitation service. 

If we followed some learning model of alcoholism and 
assumed that an indivudual slowly becomes alcoholic as 
a result of years of drinking, then we would assume a 
positive correlation between alcoholism and length of 
service. This was not supported in the present study. A 
person with many years of service was no more likely to 
have a serious alcohol problem than was a person with 
very little service time. This supports the disease con- 
cept of alcoholism which suggests that the alcoholic is 
alcoholic when he takes that first drink. It also supports 
the similar notion that alcoholism is not due to any 
cumulative effect. 

The small number of officers and women included in 
this experiment suggests that these groups, for some 
reason, tend not to be referred for alcohol treatment 
even when treatment is indicated. Could it be that 
similar to good co-alcoholics, some of us protect officers 
and women? 



28 



U.S. Navy Medicine 



(Continued from p. 1) 

provide the primary motivating 
forces which leads to the desired 
action and unity of effort of your 
people. Your personal leadership, 
fused with your level of authority, 
must encourage, inspire, teach, 
stimulate, and motivate all the 
people with whom you work. Do this 
and you will get the job done. Better 
yet, you will get it done well, and 
enthusiastically, as a team. 

Behavioral scientists tell us that 
there is one quick way to lose 
members of a team, however, and 
that is to fail to use them to the 
fullest extent. The now familiar 
sports expression, "play me or 
trade me," may have meaning for 
managers of organizations as well 
as baseball teams. Our problem is, 
of course, that we have so few 
"trades" we can afford to make for 
our experienced people these days; 
like the Redskins, our "draft 
choices" are practically exhausted. 
We do have some members of our 
team, however, whom we have the 
opportunity to "play" more effec- 
tively. In this instance, 1 am re- 
ferring to our senior and master 
chief petty officers. 

Recently I met with a group of 
E-8's and E-9's attending the four- 
week Health Resources Manage- 
ment Course here at the Naval 
School of Health Sciences. These 
knowledgeable and experienced 
leaders are ready, willing, and able 
— with training — to take on greater 
responsibilities. I would ask you to 
consider, carefully as you go to your 
commands, just what you can do to 
improve the retention and utiliza- 
tion of our valuable resource of 
health care providers. One sure way 
to keep them "coming back for 
more" is to give them more respon- 
sibility, and the commensurate 
authority, to do a more challenging 
job. Work, too, on their professional 
development, particularly those 



who have had an opportunity to 
complete formal management train- 
ing at this school. This is a source of 
talent available to you. Use it! 

Think, for example, of some of 
your more important functions such 
as contact point management and 
training, functions where experi- 
ence and cool headedness are indis- 
pensable. For the most part, our 
senior staffs are mature persons 
who have developed that necessary 
compassion and know-how to create 
and maintain in the minds of our 
patients, that most desirable per- 
ception — a favorable impression of 
the Navy health care system. You 
will note that I said contact point 
management and training. I have 
been told our contact point function 
is improving and that is most en- 
couraging. But we need to do more. 
We need to identify every patient 
contact point and monitor each and 
every one of them every day, and in 
some instances, even more often. 
We need to make sure that every 
person, military and civilian, before 
being assigned to any clinical or 
support service, knows precisely 
what is expected of him in his effort 
to provide service, and to satisfy 
every reasonable need of every pa- 
tient. Perhaps, most importantly, 
we need leadership in this effort — 
and we need it on the firing line, 
where the patients are. I would sug- 
gest that it would be very beneficial 
to have the cool and experienced 
hand of one of our senior enlisted 
persons readily available to manage 
— and avoid — those seemingly in- 
nocuous incidents we've all experi- 
enced at contact points, incidents 
which, if mismanaged, soon lead to 
administrative crises and to bad 
press. I'm sure no one here would 
complain about not having enough 
work to do. Why not give your ex- 
perienced enlisted people more op- 
portunttes to help you? 

Speaking of increased responsi- 
bility and authority for master and 



senior chiefs, I hope that each of 
you will fully utilize the know-how 
of these proven leaders in support- 
ing the sailors and marines in our 
forces afloat and ashore. In most 
instances, our chief hospital corps- 
men and dental technicians have 
been there — in the ships, and with 
the marines. This is a reservoir of 
knowledge that must be fully uti- 
lized — and utilized for the good of 
all. 

Gentlemen, leave here with a re- 
newed awareness of how much the 
accomplishment of our mission de- 
pends upon how well we train, 
utilize, lead, and retain our people. 
Having been trained, become 
trainers yourselves, and help your 
shipmates benefit from your experi- 
ences. Put your human assets on 
the balance sheet and take stock of 
them from time to time. Work hard 
to keep the talent we have and to 
keep yourself professionally sharp. 
These days of fiscal constraints 
and cost containment will test your 
mettle for efficient dollar and mate- 
riel management. These may be 
areas wherein the physicians among 
you may not have been required to 
concentrate as much attention. Now 
is the time to change that and place 
these elements in their overall per- 
spective. 

Soon the whole picture will be 
yours to consider, manage, be re- 
sponsible for, and possibly and 
most importantly, to be accountable 
for. 

Do not feel overwhelmed. A calm 
awareness is a more fitting mood. 
Remember, gentlemen, you are 
better off then Columbus. He didn't 
know where he was going. He 
didn't know where he was when he 
got there, and when he returned, he 
didn't know where he had been. 
You will have all the figurative sea 
charts to tell you where you are and 
where you are going. Self audit and 
accountability will tell you where 
you have been. 



Volume 70, June 1979 



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